acase@tulane.edu / Background: For the past two decades, Louisiana’s health status has ranked among the lowest in the nation. In 2009, Louisiana was ranked 47th in the nation which indicated marginal improvements from their 49th position in 2008. 1, 2 In addition, the 2009 Commonwealth State Scorecards Report ranked the Louisiana health system performance, in terms of health outcomes, among the poorest in the nation.One reason for this disparity could be attributed to shortages of physicians and other healthcare resources in the state. These shortages were exacerbated by the damage done by the 2005 hurricanes to hospitals and physicians’ practices in New Orleans, and throughout the state.3 Today, 86 percent of Louisiana parishes are designated health professional shortage areas by the Health Resources and Services Administration Shortage Designation Branch (HRSAS). 4 Specifically, 126 areas in Louisiana are considered as primary care shortage areas. 5 Louisiana is ranked 6th in the nation in percent of the population lacking access to primary care. 5According to the Medical Education Commission, approximately 40 percent of Louisiana’s medical school graduates and physicians leave the state after completing their medical residencies. 6 Study Design: Using data from the 2006-2007 Louisiana State Board of Medical Examiners (LSBME) providers’ data set and the 2007-2008 Blue Cross Blue Shield (BCBS) of Louisiana providers’ data to report active physicians by specialty and location in the state, this cross-sectional study analyzed disparities in statewide health system performance, measured by mortality amenable to healthcare (MAHC). Age-adjusted standardized mortality rates (ASMR) from all conditions amenable to healthcare were derived and extracted from the Centers for Disease Control and Prevention (CDC) The Distribution of Physician Workforce in Louisiana: Implications for Outcomes of Care Compressed Mortality File (CMF).7 The CMF is a county-level national mortality and population database spanning the years 1968-2006. The model controlled for sociodemographic factors and health care resources available in the different parishes. Population data were obtained from the 2006-2007 county-specific Area Resource File (ARF). The unit of analysis was the parish. Results: Louisiana is facing a maldistribution of physicians by specialty (primary care vs. specialty care) and geography. Furthermore, throughout Louisiana, health system performance as measured by ASMR from all conditions amenable to healthcare varied widely. Conclusion: Variations in parish physician supply did not explain variations in MAHC. Rather, significant associations were found between socio-economic factors and MAHC / 1 / Maysoun Dimachkie Masri

Magister Scientiae (Occupational Therapy) - MSc(OT) / The recovery process for traumatic brain injuries (TBIs) can be lengthy and taxing on the patient, family and healthcare resources. Part of this recovery process includes interventions for the improvement of executive functioning (EF) required for high level functioning such as return to work (RTW). However, evidence for best practice interventions to improve EF for RTW post TBI is lacking. Randomised control trials (RCTs) evaluating interventions for EF for RTW post TBI are available but have not been synthesised. The review aimed to determine the best practice interventions for improving EF for successful RTW post TBI. Method: A systematic review using a predetermined search strategy to find relevant titles published from inception to June 2020 in six electronic databases (EBSCOhost and PUBMED [both including MEDLINE]; CINAHL, Cochrane Database for Systematic Reviews, OT Seeker, and Taylor and Francis Online) was conducted following ethics approval by the Institutional Ethics Review Board. / 2023

Similar to other healthcare systems worldwide, Kuwait faces challenges of increased demand and cost while trying to operate with constrained resources. There are some data suggesting that Lean methodology, first used by Japanese car manufacturer Toyota, could improve system efficiency or flow by waste elimination, may be useful in addressing some of the challenges found in healthcare. Lean has so far not been used in Kuwaiti primary healthcare centres. This thesis explores the case for using Lean in Kuwait by examines issues around diabetes, as Kuwait rank the six highest in the world. In Kuwait, patients with diabetes are mainly managed in primary healthcare centres. The case for using Lean was explored across five interrelated studies which are summarised below: Study 1 involved a review of the literature which found that Lean tools have been used mostly in hospital settings without any rigorous evaluation and with little or no attention paid to primary healthcare or in developing countries. Study 2 was a systematic documentary review of the challenges facing the healthcare system of Kuwait. In Kuwait, expenditure on healthcare services is expected to double within five years. Life expectancy is increasing, while the percentage of the elderly population is growing, leading to increasing demand of services to treat non-communicable disease such as diabetes. Kuwait still sends many of its patients overseas for treatment. Currently, 10 mega projects worth approximately 2 billion Kuwaiti Dinar are being constructed in Kuwait that will result in a doubling of the bed capacity. However, the average occupancy rate between 2006 to 2015 was 63.6%, which is considered low compared to the average occupancy rate in European Union countries. Study 3 sought the views of Kuwaiti healthcare leaders about Lean and challenges facing the healthcare system of Kuwait. The key findings were: (1) Most leaders agreed that the current healthcare system in Kuwait faces difficult challenges and needs to change its management approach; (2) Lean as a management approach is considered a new concept among leaders of Kuwaiti healthcare organisations; (3) They did not have adequate knowledge regarding Lean but were willing to support any future Lean improvement initiatives. Study 4 explored the knowledge of Healthcare Workers regarding Lean within Kuwait’s primary healthcare centres through a cross-sectional survey in four primary healthcare centres. Only 11% of participants were familiar with Lean. None of the participants were involved or had an ongoing Lean initiative or project but 80% of participants were willing to be involved in future Lean initiatives. Study 5 mapped the flow of patients with type 2 diabetes in primary healthcare centres to identify potential waste and make recommendations for improvement. Patients with type 2 diabetes typically visit their General Practitioner at least every two months for a review appointment. When a blood test is required to monitor blood sugar levels, three more visits are required, involving the blood test, collection of test results by the patient and a review of the results with the general practitioner. Four potential improvements were identified: using point of care testing, the posting of laboratory results to general practitioner computer systems, the introduction of guidelines that standardise the practice for the patient’s visit and permitting the general practitioner to prescribe medication that will last four months. The process map of patients with type 2 diabetes has highlighted waste and improvement suggestions that may reduce workload, enhance patient satisfaction, avoid unnecessary visits, enhance the timeliness of laboratory testing, improve communication between and across departments and minimise the use of resources without undermining the quality of care. These suggestions, if implemented on the national level, could bring tremendous benefits but still need to be rigorously evaluated. The thesis concludes by noting that there is considerable potential in adopting Lean to improve the healthcare services in Kuwait, but further work is required to implement the changes and rigorously evaluate them.

This study examined the role of health care access and health care resources in the association between subjective aging and activities of daily living among older adults. We examined subjective aging in the context of subjective cognitive decline (SCD) relationships in three studies: (1) a scoping review of healthcare access (HCA) and resources (HCR) on dementia and COVID-19 among African American older adults; (2) subjective cognitive decline in basic activities of daily living (bADL) across age cohorts, older adults and (3) subjective cognitive decline in instrumental activities of daily living (IADL) across older adults' moderation by HCA and mediation by HCR. For the scoping review, we utilized the population, concept, and context inclusion and exclusion criteria for study admissibility for articles published on dementia and COVID-19 studies in English language journals that published from January 2019 to December 2022. The two empirical studies utilized the 2021 round 11 of the National Health and Aging Trends dataset of older adults aged 70 to above 90 funded by the National Institute for Aging. We employed multiple regression and the bias-corrected percentile Bootstrap with 5000 samples using standard path-analytic approaches for the moderated-mediation approach for the two empirical studies. Findings from the scoping review indicated racial and age disparities affected older African American adults with dementia and COVID-19, associated with lower HCA and marginal HCR. Results of mediation–moderation analysis showed SCD, lower HCR, and HCA predict a decline in bADL to be higher among the older-old age (80-89) compared to the middle-old age (70-79) or oldest-old (90 years +) cohorts. We observed similar effects for IADL. The findings from the two empirical studies suggest a "doughnut" effect by which the older-old age cohort of 80-89 may be coping less well with their bADL, as well as IADL, while the oldest-old may have adapted to functional loss in their everyday living and/or comprises adults who may have passed a mortality selection despite a more significant burden of comorbidity.